尿路感染

UrinaryTractInfectionInfection:growthof>105organismspermilliliterfromaproperlycollectedmidstream“clean-catch”urinesampleAnatomiccategories:upperurinarytractinfection：Pyelonephritislowerurinarytractinfection：Cystitis,urethritisEpidemiologicalcategories:Catheter-associatedCommunity-acquiredDefinitionsSymptomaticAsymptomaticDysuria,frequency,urgencyEPIDEMIOLOGYGeneralpopulation0.91%Women2.05%Nonpregnantadultwoman5.0%Pregnantwomen7%Elderlywomen10%infant1.0%SchoolGirls1-2%SchoolBoys0.03%Elderlymen(>50yrs)7.0%*Datafrom30,196women1stAffiliatedHospitalofSunYatsenUniUSA:Acutecystitis:36millionptsperyear(18-75y);cost16hundredmillion$.Episodesofacutecystitisinfemale:11%peryearApproximately50%-60%ofadultwomenreportthattheyhavehadaUTIatsometimeduringtheirlife.EPIDEMIOLOGYEtiologyMicroorgnisma:Bacteria,fungi,virus,Chlamydiatrachomatis,MycoplasmaThemostcommonagents:thegram-negativebacilli.Escherichiacoli:70%ofacuteuncomplicatedUTIStaphylococcussaprophyticus:5%-15%inyoungwomenProteusmirabilis,Klebsiellaspecies,enterococciorotheruropathogensCASE1—A32year-oldwomancomplainsofdysuriaandfrequency;pyuriaisseenintheurinesediment.Gramstainofunspunurine(x1000)showsaninflammatorycellandnumerousGramnegativebacilli.Escherichiacoligrewfromthisspecimen.CASE2—A65year-oldwomancomplainsofdysuriaandfrequency;pyuriaisseenintheurinesediment.Gramstainofunspunurine(x1000)showsinflammatorycellsandGrampositivecocciinchains.Enterococcusfaecalisgrewfromthisspecimen.CASE3—An18year-oldwomancomplainsofdysuriaandfrequency;pyuriaisseenintheurinesediment.Gramstainofunspunurine(x1000)showsinflammatorycellsandGrampositivecocciinpairsandclusters.Staphylococcussaprophyticusgrewfromthisspecimen.CASE4—Thisspecimenwasobtainedfroma42year-olddiabeticwomanwithaFoleycatheter.Gramstainofunspunurine(x1000)showsGrampositivebuddingyeastsandlargepseudohyphae.Candidaalbicansgrewfromthisspecimen.PathogenesisSourcesofinfectionPredisposingfactorLocalandsystemichostdefensemechanismsPathogenicityofthestainAscendinginfectionHematogenousinfectionLymphathicwaySourcesofinfectionAscendinginfection:Bacteriagainaccesstobladderviaurethra,orfollowbyascentfrombladdertorenalparenchyma.EntericG(-)organisms:colonizeontherectalintroitus,theperurethralskin,anddistalurethraStaphylococcalspecies:thevaginalintroitus,anddistalurethraFacilitatedbythefactorssuchassexualintercourse,contraceptive(spermicide)Genderandsexualactivity:Thefemaleurethra:colonizationwithcolonicGnegativebacilliProximitytotheanusShortlength(-4cm)ItsterminationbeneaththelabiaSexualintercoursecausestheintroductionofbacteriaintobladderandisassociatedwiththeonsetofcystitis.Male<50yrsoldwithouthistoryofhetersexualorhmosexualrectalintercourse:uncommonBacteriuiainMale:urethralobstructionbyprostatichypertrophy,bacterialprostatitisPredisposingfactorObstruction:(Hydronephrosis)tumor,stricture,stone,prostatichypertrophyvesicoureteralreflux,NeurogenicbladderdysfunctionUseofinstruments：cystoscopy、urethralcatheterizationorindwellingurethralcatheterMalformationandstructuralabnormalities:posteriorurethralvalvedysfunctionPredisposingfactorUrethraorperiurethralinfection：genitalinfection、bacterialprostatitisRenalparenchymalesion：Diabeticnephropathy、PolycystickidneyPoorimmunity：useofimmunosuppressiveagents、kidneytransplantation、renalfailure、systemicdiseaseDefectoflocalmucousmembraneofurethradefenseabilityPredisposingfactorFlushinganddilutionaleffectsofvoidingAntibacterialofurine:lowpH,highosmolarity,highureaconcentrationAntibacterialofthebladdermucosa:Secretionoforganicacidsandantibodieseg.IgAAntibacterialofprostaticfluidBarriereffectofsphincterofurethraLocalandsystemichostdefencemechanismsBacterialvirulencefactors Ecoli:specificO,K,andHserogroupsClinicalManifestationCystitisPyelonephritisAsymptomaticbacteriuriaUncomplicatedUTIsComplicatedUTIsRecurrentUTIsReinfection:differentstrains,>1month,CystitisRelapse:thesamestrain,<1month,pyelonephritisClinicalManifestationCystitisacutepyelonephritisDysuria,frequency,urgencyobviousobviousFever,shakingchillsnoneshowedCostovertebralanglestenderness/sensitivetopercussionnoneshowedWBCmostlynormalincreasedpathogenicbacteriumEscherichiacoli（75%)coagulasenegativestaphylococcus（15%）Escherichiacoli、bacillusproteus、KlebsiellaComplicationBacteremiaorSepticemiaPapillarynecrosisDM,pregnancy,urinaryobstructionHematuria,painintheflankorabdomen,chillsandfever,ARFNecrosistissueispassedintheurineRingshadowonpyelographyPerinephricabscessLaboratorytestUrinalysisLeucocyturia(Pyuria)UrinecultureOther：WBC(leukocytosis)、Erythrocytesedimentationrate(ESR)、intravenouspyelography(IVP)andC-reactiveprotein.Urinalysis:Whitebloodcellcasts-PyelonephritisPyuria:Highsensitivity,butspecificitywasonly70%Urinarysedimentofcleaningurinespecimen:WBC≥5/HP,810/L,WBCesterasetestpaperpositiveLeukorrheacontaminationsterilepyuira:unusualinfectionsuchastuberculosis,fungi,chlamydia/mycoplasmainfectionNoninfectiousurologicconditionssuchasinterstitialnephritisUrinecultureSuprapubicaspirates:qualitativecultivation(Goldenstandard)Qualitativebacteriologicalcultivation:voidedmidstreamurinesample(cannotdiagnose)Quantitativevoidedmidstream“clean-catch”urinecultures105/mlsignificant104-105/mlsuspensive,needreexamination104/mlcontaminative*ForG(+)coccus>103/mlsignificantUnspun,clean-catchurinespecimen,andGram’sstain1bacteria/HP105/ml(95%)Bothsensitivityandspecificityare92%Midstream“clean-catch”urinesediment:20bacteria/HPChemicalexaminationNitritestest(GriessTest):nitricacidnitrousacid(gramnegativebacilli)sensitivity:70.4%,specificity:99.5%EnterobacteriamostlypositiveEnterococcus、staphylococci、StreptococcusfaecalisareusuallynegativeUrinedipsticks ：leukocyteesterase,GriessTestScreeningtestFalsepositive&negativeinUrinecultureFalsepositive:Urinesamplewascontaminatedbyleucorrhea,etc;Urinesamplewasputatroomtemperatureformorethan1hourbeforeinoculated;Technicalerrors.Falsenegative:Usedofantibioticsinthepreceding7days;Frequency:Urinestayedinthebladderforlessthan6hours;WaterdiuresisorrecentvoidingDisinfectantinterfuseintourine;Anaerobe、chlamydia、fungiorothermicroorganisminfection.OtherexaminationWBC(leukocytosis)ESR,C-reactiveproteinIntravenouspyelography(IVP)RecurrentUTIscomplicatedUTIs:stoneRecurrentpyelonephritisunusualbacteriainfectionsAhistoryofUTIinpregnancyAhistoryofchildhoodinfectionsMalewithUTIPainlesshematuriaRenaltubulefunctionVesicoureteralrefluxtestduringvoidingforbidtoperformatacutephase!DiagnosisDependontheurineculture,lessontheclinicalsymptomsandsigns.Patientwithbacteriuria:diagnosisasUTI。WomenwithobvioussymptomsandpyuriacanalsosuspecttobeUTIs,ifmidstream“clean-catch”urinecultureswas>102/mlPresenceofbacteriainsuprapubicaspiratessample.Insymptomaticpts,midstream“clean-catch”urinecultures≥105／ml.Inasymptomaticpts,2consecutiveurinespecimensshouldbeexamined,and≥105/mlbacteriaofasinglespeciesshouldbedemonstrableinbothsamples.BacteriuriaLocalizationofinfectionSymptomsandsigns:pathogenicbacteriaTubulefunctionandleukocytecastReviewof3daystherapyUrinespecimencultureafterbladderirrigationAccuracyismorethan90%ThemostvaluablemethodforlocalizationdiagnosisnowToocomplexandtime-consumingOnlyuseforscientificresearchPyelonephritisSystemictoxicsymptoms：T>38℃，WBC，costovertebralangletenderness/sensitivetopercussion,leukocytecast；Recurrentinthenext4weeksaftertreatmentComplicatedfactorssuchasobstructionormalformation；Unusalbacteria:Aeruginosusbacillus,Streptococcusfaecalis,Bacillusproteus;Remainrenaldysfunctionaftertreatmentwithoutotherreasons;IVPshowsabnormalimage.Reviewof3daystherapyNosymptomsCultivationisnegativeNonsepticUrethralsyndromeWomanwithurethralsymptoms3daystherapy（TMP-SMZ2#Bid/Ofloxacin0.2gBid）UrinalysisandurinebacteriacultureCystitis(cure)SymptomrelapseandCultivationispositiveoccultpyelonephritisWithsymptomspyelonephritisCultivationispositiveUrethralsyndromethatcausedbychlamydiatrachomatis.ShouldexcludTBfirst.7dayslater1W~1MleucocyturiaNoleucocyturiaCultivationisnegativeCultivationisnegativeDiagnosticprocedureofUTIUTIupperUTIacutepyelonephritislowerUTIchronicpyelonephritischronicpyelonephritis:pyelographyorultrasonicexaminationcortexscarsandkidneypelvis/calicesdeformedrenalsize:asymmetric,decreasepersistentlytubuledysfunctionDifferentialDiagnosisSystemicinfectionDiseasesChronicpyelonephritisRenaltuberculosisUrethralsyndromeRenaltuberculosisConditionsfollowedshouldbesuspectedofrenaltuberculosis1．Chronicirritationsymptomsofbladder,antibioticsshowednoefficiency,especiallythoseprogressivelyaggravate.2．Pyuria,Aciduria,generalbacteriologyexaminationwasnegative.3．Extrarenaltuberculosis,hematuria4．Epididymis,spermaticcordorprostatetuberculosis5．Pyuriapersistentlyexistaftereffectiveantibiotictreatment,urinebacteriaculturenegativeRenaltuberculosisConfirmeddiagnosis：(anyoneofthefollowingthreeconditionscanmakeadiagnosis）1.Clinicalmanifestation+urinetuberclebacillusculturepositive.2.X-RayindicatetypicalmanifestationofrenalTB.3.Cystoscopyshowedtypicallesionofcystitistuberculosa.UrethralsyndromeInfectiousUrethralsyndrome:Acuteurethritismycoplasmaorchlamydiachlamydialinfection:Azithromycin(1ginasingleoraldose);Doxycycline(100mgtwiceaday);OfloxacinNoninfectiousUrethralsyndrome:womenwithacutedysuriaandfrequency,negativeurineculturesandnopyuriaNoantimicrobialtreatmentMayrelatedtodrynessoftheurethralandvaginalmucosainpostmenopausal,estrogen-deficientwomen,psychologicalstatussuchasanxietyTreatmentPrinciplesTreatmentfordifferenttypesofUTIsPrinciple(1)Urineculture:Who:ExceptinacuteuncomplicatedcystitisinwomenWhen:beforeempiricaltreatmentisbegun.Howtousethecultureresults:antimicrobialsensitivitytestingshouldbeusedtofurtherdirecttherapy.Principle(2)Factorspredisposingtoinfectionshouldbeidentifiedandcorrectedifpossible.obstructionandcalculiIngeneral,uncomplicatedlowerUTIsrespondtoshortcoursesoftherapy,whileupperUTIsrequirelongertreatment.Principle(3)Antibioticsselection:FirstchoseantibioticswhichwereeffectivetogramnegativebacilliTMPandFluoroquinolonecanbeusedempiricallyasfirstlinedrug.Thepresenceofantibiotic-resistantstrainsshouldbesuspected:inptswithrepeatedinfections,instrumentation,orrecenthospitalization,andantimicrobialsensitivitytestingshouldbeused.Principle(4)Therapeuticjudgments:Reliefofclinicalsymptomsdoesnotalwaysindicatedbacteriologiccure.ptshouldbefollowupat2wand6waftercessationoftreatment.Acure:resolutionofsymptomsandeliminationofbacteriuria.Afailure:Presenceofbacteriuriawithorwithoutsymptoms.Principle(5)Therapeuticjudgments:RecurrentinfectionsshouldbeclassifiedasRelapse:thesame-strainoccurringwithin2weeksoftheendoftherapy.(anunresolveduppertractfocusofinfection;persistentvaginalcolonization)Reinfection:recurrences>2weeksafterthecessationoftherapywithanewstrain.TreatmentfordifferenttypesofUTIsAcuteuncomplicatedCystitisinwomenAcuteuncomplicatedpyelonephritisRecurrentUTIsUTIsinPregnancyUTIsinMaleCatheter-associatedUTIsAsymptomaticbacteriuriaUTIsinChildrenCommonorganisms:EcoliorStaphylococussaprophyticussingle-dosetherapy:Taketheantibioticsforonlyonetimewitharelativelylargedose(SMZ（SMX400g，TMP80mg）6pillsdraught/TMP0.4gdraught/Ofloxacin0.6gdraught).morefrequentrecurrences3-daystherapy:EradicatevaginalandrectalfloracolonizationwithEcoliTMP-SMZ2#Bid/Ofloxacin0.2BidThebestchoiceis3daystherapy!AcuteuncomplicatedCystitisinwomen7-to14dayregimen:theshort-termtherapyshouldnotbeusedDiabetesptswiththeimmunosuppressivetherapypreviousinfectionsduetoantibiotic-resistantorganismsUTIsymptomsfor>7dUTIinpregnancyage>65yrsmaleswithUTI(urologicabnormalitiesorprostaticinvolvement)UseofdiaphragmAcuteuncomplicatedCystitisinwomenAntibioticstherapy:14dayscourseEmpiricaltreatment:Fluoroquinolone,thethirdgenerationcephalosporinoraminoglycosideSensitivetoG-Bact.(Ecoli)LessnephrotoxicityandsideeffectsHighconcentrationinrenalandurine.Intravenouslythefirstfewdays,takingorally72hrsafterfeverrelieving.AcuteuncomplicatedpyelonephritisAcuteuncomplicatedpyelonephritis14daysantibioticscourseAcuteuncomplicatedpyelonephritisFollowupatthe2ndwkand6thwksFailurewithin72hrrelapseRelieffromsymptomsandeliminationofbacteriuriaCureChangeABs:accordingtodrugsensitivetest6wks’ABstherapypredisposingfactors:unrecognizedsuppurativefocicalculiurologicdiseaseExistingthepredisposingfactors:catheterization,instrumentation,urologicanatomicorfunctionalabnormalities,stone,obsrtuction,immunosuppression,renaldisease,ordiabetes.Hospital-acquiredbacteria:Ecoli,klebsiella,Proteus,Serratia,pseudomonas,enterococci,andstaphylococci.Antibiotic-resistentComplicatedUTIsEmpiricalantibiotictherapy:Broad-specturmcoverageagainstthosepathogensImipenemApenicillinorcephalosporinPLUSanaminoglycoside,orceftriaxoneorceftazidimeAmorespecificantimicrobialregimencanbeselectedontheantimicrobialsensitivitypattern.10-21daysFollow-upcultures2-6wksaftercessationoftherapy.ComplicatedUTIsRemovalofcatheterShortcourseofantibiotcsIfthecathetercannotberemoved:Asymptomaticbacteriuiashouldbeignored.Theptdevelopssymptomsorinhighriskofdevelopingbacteremia:ReplacementofthecatheterSystemicantibioticChangingthedrainagewayifnecessary(suprapubiccystotomy).Catheter-AssociatedUTIsAsymptomaticbacteriuria/AcutecystitisAllpregnacywomenshouldbescreenedforasymptomaticbacteriuriaduringfirsttrimester(4%-7%).7daysofantibioticstherapyTheincidencerateofprematuredelivery、lowbirthweightwillincreaseifwithouttreatment.Antibiotics:lowtoxicitysuchascephalosporin,Ampicillin,Amoxicillin.UTIsinPregnancyAcutepyelonephritisParenteralantibiotictherapycephalosporin,orextended-spectrumpenicillin.UTIsinPregnancyUrinecultureshouldbeperformedtoensurecure,andrepeatedmonthlyuntildelivery.UTIsinPregnancyRecurrentinfection:continuouslow-doseprophylaxiswithnitrofurantoin.AntimicrobialtherapyisunnecessaryintheElderlypts.Antimicrobialtherapyisnecessary:High-riskptswithneutropenia,renaltransplants,obstruction,orothercomplicatingconditionsPreschoolchildren7daysoforalantibioticstherapyinitiallyAsymptomaticbacteriurialonger-termtherapy(4-6wks)inhigh-riskptspersistentasympomaticbacteriuraMonitoringwithoutfurthertreatmentBacteriuriareoccursaftercessationoftreatment.Reinfection:differentstrains,>2wks,CystitisRelapse:thesamestrain,<2wks,pyelonephritisAbout80%oftherecurrentUTIsarereinfection.RecurrentUTIsAshort-termantibioticstherapyinitially.Follow-up:1or2wksaftercessationtherapy.Relieffromsymptomsandeliminationofbacteriuiaandleucocyturia:Reinfectionisindicated.Theprevioustreatmentwaseffective.Recurrentfrequently（2timesinhalfayearor3timesin1year):long-term,low-doseantibioticstherapy(bacteriostasis).Dailyorthrice-weeklyadministrationofasingledoseofnitrofurantoin50mg,TMP-SMX80/400mg,ofloxacin200mgpernightafterurinateHalfayearormayprolongto1~2yrRecurrentUTIsFailuretotherapy,thefollowingconditionsshouldbeconsidered:Antibiotic-resistant:ChangetoasensitiveABsfora7daystherapyaccordingtodrugsensitivetest.Reinfectioniftheantibioticworkswell.Relapseiftheantibioticdoesnotwork.:samestraininfectionpyelonephritisProlongtreatmentto6wks.Iffailed,prolongthecourseoradministerparenterally.CheckthepredisposingfactorsRecurrentUTIsHistoryofrecurrentUTIs,withUTIsymptomsShort-termtherapyReview7dayslatereffectivereinfectionsensitiveantibioticsLong-termlow-doseantibioticsfailureeffectivefailurepyelonephritis6wksantibioticstherapyCheckthecomplicatedfactorsrelapserecurrentUTIsfrequenclyAntibiotic-resistentRecurrentUTIsPrognosisUncomplicatedUTIs:completeresolutionofsymptom(>90%);rarelyprogresstorenalfunctionimpairmentandchronicrenaldisease.ComplicatedUTIs:developtochronicpyelonephritis,difficulttocureunlesscorrectingthosepredisposingfactors.PreventionDrinkmorewaterPersonalhygiene:pudendumcleaningforfemalepts,redundantprepucecleaningformalepts.Avoidingusinginstrumentsaspossible,andstrictlyfollowingasepticmanipulationifnecessary.Vesicoureteralreflux:Toestablishahabitthatvoidonceagain.PreventionWomenwithfrequentsymptmaticUTIs(3peryr):Longtermadministrationoflow-doseAbsAvoidspermicideusevoidsoonafterintercourserecurrentUTIsrelatedtointercourse:Thesameregimensasabovecanbeusedaftersexualintercourse.Thanks！